13 May 2009

A reader has suggested it would be better to pull the post entitled 'Bloody Solicitors'. He's right. Dr G was angry and posted very unwisely.

There is quite a lot more that Dr G does not publish. Sometimes it is very clear where to draw the line. Sometimes things are a bit grey. Sometimes what Dr G says is heavily disguised. Sometimes Dr G gets it wrong for emotional reasons. He's grateful to his readers for pointing out when he oversteps the mark.

Posted by
Dr Grumble

12 comments:

Mrs Dr Aust has been sued. Scenario was that patient (serious chronic illness managed as outpatient) wouldn't wait to be seen in monumentally backed-up clinic by shockingly overstretched junior doctor - Mrs Dr Aust, of course. The pt left, then died at home o/night. However, the pt hadn't signed a form to say "I understand the doctors want me to stay and be seen, but I'm going home". Family sued, case settled out of court after much stress. The unjust thing as I saw it was that Mrs Dr Aust, and what she had done, was squarely in the crosshairs, though the problems that day were emphatically not of her making - "organisational constraints" etc etc.

Mrs Dr A has also been deposed a couple of times when the boss consultants she worked for were on the receiving end of legal action.

I tend to tell the medical students that being sued is an occupational hazard, with likelihood depending on specialty. But, judging from what I saw of Mrs Dr Aust's experience, such things take a toll on junior doctors who end up at the sharp end of them.

These things do take a toll, Dr Aust. There are stories that I can tell about doctors who have been so upset by unjustified claims against them that they have taken early retirement or even emigrated. Of course it is not the sensitive doctors that are a cause of concern. It's the thick skinned ones that are unaware of their limitations that you need to worry about. These people are unruffled by solicitors. You clearly have some experience of how damaging these sharks can be, Dr Aust. Mr Fotze of Fotze and Moese No Win Solicitors is not doing a public service he is just a parasite who is mostly interested in his own welfare.

It apparently baffles solicitors that we take a such dim view of them. Curiously enough two of my mouse pads come from a firm of solicitors who seem to expect me to point likely victims in their direction. When you see how much the miners' solicitors made and how little the miners themselves got it makes you think twice about setting patients on the compensation pathway.

Yes, Mrs Dr Aust took it very hard, and very personally, although of course strictly speaking it was the Trust that was being sued. It was not a happy time at Casa Aust, anyway.

Quite agree about the toll of the job. The worst thing, as you say, is that the better the doctor, and the greater their self-insight - qualities that are of course highly desirable - the harder they take things. Meanwhile, the less skilled and insightful breeze on through.

PS Dr G, what do you think of the argument that Trust complaints procedures can actually encourage legal claims by preventing people from explaining and even apologising to patients and relatives? I notice that in the recent case of the German OOH GP and the fatal diamorphine overdose, his having written an apology to the family was deemed very odd, certainly by the newspapers covering the story.

If a patient has some silly unwarranted complaint or grouse and is being a nuisance Dr Grumble sends them to PALS which pretty soon bogs them down, takes them off our backs but may give the patient the illusion that somebody is taking them seriously. If anything really has gone wrong Dr G deals with it himself and tries to avoid all official processes. Unfortunately complaints that reach the complaints department tend to languish in a bureaucratic process then, after a lag, get sent to all relevant people for comments after which a manager compiles a long, usually bad, reply. By then months have passed. For some things it is appropriate but it's best to deal with these things promptly yourself if at all possible.

I don't want to comment on the GP case but Dr Grumble, even if appropriately qualified, would never take an out of hours unsupervised locum in a foreign country in which he had had no experience. It is asking for exactly the sort of mistake which occurred. No system should allow this. I doubt it could have happened before European harmonisation.

Mrs Grumble (ex-GP) would never have taken a fly by night locum to do her out of hours. But that was in the days when GPs and not private companies were in charge of out of hours care.

Why don't these people have a proper induction which would involve in depth training on the ways of the UK system, the drugs they need to be familiar with etc?

This is an interesting case, and I read the original post before you took it down, Dr G. As a practising full-time GP, I think that the GP case is indefensible: a first year undergraduate would know that this is a potentially fatal dose of Diamorphine.

The Government decided that they could run the out-of-hours service better and cheaper than GPs, so offered us a deal that most of us did not refuse.

It is they, the SHA, the PCT, the commercial firm running OOH services that should share the blame and not just a possibly incompetent doctor.

The hospital case that you describe is in many colleague's experience.

It reminds me of the old joke about a liner that sank when having a conference of 1500 lawyers - what would you call that?

Sorry to hear your news about litigation. If you fancy a therapeutic 'share', my email is editorial at healthpolicyinsight.com - I have something to share offline over the OOH GP thing, which I hope you'd enjoy.

The respondent's answer in Arkell vs. Pressdram (1971) is always first to my mind when I hear such news, but that's why I'm in my line of work.

Mrs Dr Aust points out that diamorphine is not used at all in Germany, where the GP in the OOH death came from. So he would never have given diamorphine, and would not know the doses. Of course, he could / should look them up. Anyway, the assumption might be that he looked for the drugs he was familiar with, couldn't find them.... etc. I was guessing this was part of what what Dr G was referring to as "proper induction" before being allowed to start work.

BTW, we don't teach drug doses any more in the pre-clinical years. So maybe " 3rd or 4th yr medical student".

Back to the OOH death, Mrs Dr A tells me an ampoule with 100 mg diamorphine is for an infusion, not for IV injection (those ones being 5 mg), and presumably is marked as such:

For continuous infusion use ONLY

NOT for IV injection" ...??

Obviously you would know all this, but I don't, which is why I was asking 'Er Indoors. She also muttered something like:

"This is why medical students and junior doctors get taught to read the label on the drug vial three times, then read it out loud to someone else, then ***!"! read it again".

Of course, single handed in the middle of the night cuts down some of these options, though you could presumably read out the label to the relatives.

Re. the GP OOH services, ours used to be a local GP co-op, which as "customers" we found to be pretty good. However, it is all change, and when Jr Aust got a nasty 1 wk+ persistent tonsilitis w. pus the other month we were "referred" by the OOH phone no to the OOH "GP clinic" at the local (large teaching) hospital.

Imagine our surprise when we turned up there and found our, er, health professional, employed by the company which has the OOH "contract", was an adult A&E Nurse Practitioner. Luckily he was a reasonable bloke, and he and Mrs Dr Aust were able to agree on what she thought he ought to do.

I don't think the Americans use diamorphine either. I have been involved in a few episodes (none my fault) when things have gone very badly wrong and it often turns out to be a chapter of accidents. Sometimes several things were done wrong in sequence. If any one of several people had done their jobs properly the serious adverse event would never have happened. This GP case seems to be the same.

The first mistake was recruiting a doctor from Germany and giving him drugs they do not use there without an adequate induction. The second issue is the whole concept of thinking that you can just fly doctors in from elsewhere without the right in-country experience to do a job like out-of-hours medical care. The third problem is putting as much as 100mg diamorphine into an ampoule. This is like having ampoules of potassium on the ward. Dr G argued against this for year and years. However much you train people to read the label one day somebody won't or, even if they do, they will do the wrong thing with the drug. It is possible to make things safer by taking away the high risk items. The fourth problem was that the doctor presumably made some assumptions. He was tired. There might have been pressure to do something quickly. His English might not have been perfect. It does not give confidence to patients if you have to slowly read the instructions to administer a basic pain killer.

You can see how all these factors were an accident waiting to happen when all these unfortunate problems came together.

If only the company employing the doctor had only employed people with a local track record.

If only the doctor had received a prolonged induction outlining differences in UK medicine.

If only he had been supervised until he was known to be up to speed.

If only somebody had decided that 100mg of diamorphine was too much to put in the bag for routine use.

If only the doctor hadn't been exhausted.

If only he had read the package insert.

Just one of the above could have meant that this tragedy would not have happened. It is still clear where the main fault lies but there were many possibilities to lessen the chance of this happening.

Indeed-y. Mrs Dr Aust was involved in at least one truly hair-raising near miss during her time in anaesthetics, which met exactly this pattern of "small sequential errors plus sheer bad luck plus procedures which made errors more feasible".

It all serves to remind one why the sort of "systems error analysis" approach to medical errors / critical incidents is a good thing, all in all. Of course, it may be that, in the eye of the storm, apportioning blame comes to be a more prominent feature - especially if it all gets anywhere near the lawyers or the newspapers.

In Mrs Dr Aust's near-miss, none of it was her fault, but she was the anaesthetist standing there giving the drugs. Definitely the sort of settings in which the gasmen (and women) earn their corn. Her cool head was the main reason things turned out all right, but we often used to wonder how her role would have been "interpreted" had the outcome been different.

Unfortunately, as I am sure you agree Dr Grumble, often the patients who you think should sue, and have every reason to sue, don't and the ones who have no real reason are the ones who seek legal advice and increase the feelings of general disillusionment....

Yes, Kinesh. Odd that isn't it? When things go wrong, which shouldn't have, you show great and very genuine concern. Patients pick this up and end up thanking you rather than suing. It is difficult to show genuine concern for something that you didn't do wrong.

Some may realise that not much happiness comes out of the legal route.

I have taken all possibly identifiable posts down but I did tell the story here (with his permission) of a professor in the Grumble hospital who was repeatedly mismanaged in a nearby hospital as a result of junior doctors blindly following a protocol. It could have killed him but just caused bad discomfort. He did not sue and I don't think he complained formally either. We didn't even discuss whether he should. It all just seemed an unhappy route to take and he was just glad he had got away with his life and it was all over. And he delighted in telling the story over a beer. As a non-clinical but medically qualified professor he was incredulous at how sensible people will blindly follow a protocol that is telling them to do the wrong thing. In this case it was an IV heparin protocol which repeatedly told junior doctors to give too much heparin which repeatedly caused him to bleed. He pointed this out but the protocol was just followed again. It is a problem that when you give people protocols and guidelines they tend to stop thinking.

Didn't the German dr claim something about being tired? Might that perhaps have had something to do with having worked a normal week in the German system before flying over here to work for the weekend - entailing the hour shift in time. And I believe that this has quite an effect on your concentration (does me anyway!) and is the subject of articles every spring and autumn when the clocks shift. Not only are these mainland EU chaps and chapesses working as much or even more than our own GPs but they are commuting a long way too. And they are working in a foreign language (and I know a lot about that too). No - really doesn't seem a good idea to me!!!!!!